https://imcjms.com/public Ibrahim Medical College Journal of Medical Science https://imcjms.com/public/registration/journal_full_text/68 Tue, 02 Aug 2016 12:05:20 +0000 Background: Bangladesh is experiencing a plateau phase in fertility decline after its dramatic reduction in early nineties. Aspects of contraceptive use dynamics have important influences on fertility. Results: The results showed that individual level characteristics had strong influence on contraceptive use. These variables included educational level of the couples, autonomy of woman, male child preference, woman’s membership with an NGO, visit by family planning worker, region and type of residence. Ibrahim Med. Coll. J. 2014; 8(2): 34-40 Address for Corresponded: Dr. Masuda Mohsena, Associate Professor, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbag, Dhaka-1000. email: masuda669@gmail.com   Bangladesh, having a population of 140 million and a corresponding population density of more than 900 per square km happened to be one of the most densely populated countries in the world1. The policy to reduce fertility rate was repeatedly emphasized by the Government of Bangladesh since its liberation in 1971. In 1976, the Government declared the rapid growth of the population as the country’s top-most problem and adopted a broad-based, multi-sectoral family planning program along with an official population policy. Population planning was seen as an integral part of the total development process of the country and was incorporated into successive five-year plans2. There are programmatic and policy importance of understanding the choice of contraceptive method use and factors affecting contraceptive choice in order to reduce the total fertility rate (TFR) of a country5. As any future reduction in fertility in Bangladesh may be largely dependent on the increased use of effective birth control measures, identification of specific determinants of each method is needed. To facilitate that effort, by using a single model and controlling for the various factors, this study aims to 1) Analyze socio-economic and demographic determinants of different contraceptive methods choice in Bangladesh; and 2) Discuss the policy implication of the findings. Methods and Models The dependent variable in this study was “current method of contraception adopted by the woman”. BDHS 2004 collected information on pill, intrauterine device (IUD), injection, condom, female and male sterilization, periodic abstinence, withdrawal, norplant and other methods. Here four groups were considered: Non-user, folk and traditional method users were considered as one group and coded as 0. Pill users, having highest frequency were coded as 1. Permanent method acceptors (tubectomy and vasectomy) were coded as 2. Long term temporary method users (injection, norplant and IUD) were coded as 3. Condom users, as the use additionally gives protection against Sexually Transmitted diseases (STDs) and AIDS were coded as 4. The frequencies of use of these four methods were presented in Figure 1. Fig.1: Contraceptive method preferences among married couples, BDHS 2004  In the BDHS, there were many variables available related to mobility of the women. Principal Component Analysis (PCA) technique was employed to create the variables into a mobility score for each woman6. On the basis of prior knowledge of determinants of contraceptive use educational level of the women, her religion, number of living son, her membership with an NGO, husband’s education level, wealth index, age of women, her type of residence (urban/ rural), division to which she belonged were entered as independent ones in the model. These independent variables were tested for statistical significance using bivariate techniques such as chi square tests (Table 1). Finally, Multinomial Logistic Regression (MLR) model was employed to estimate the relationship between contraceptive use and socio-economic and demographic factors using SPSS software.   Among the 10,554 currently married women surveyed in BDHS 2004, 53.14% either did not practice any method or relied on folk or traditional methods. Oral contraceptive method seemed to be the most popular one having 25.4% use rate. Long term methods (norplant, IUD and injections) came out as the second most popular method (11.0%), 5.6% couples accepted either male or female sterilization method. Condom had the lowest frequency (4.8%) of use. Results of the MLR analysis are presented in Table 2. From the model ‘education level of the women’ came out as a strong predictor of contraceptive use. The probability of being a pill user was 1.24 times higher if the woman had secondary education compared to woman having no education. The probability of using condom for husbands of highly educated women (with post-secondary education) was 4 times higher compared to the husbands of non-educated women, whereas the values were almost 2.5 and 1.5 times higher for husbands of secondary educated women and those of primary educated women, respectively. Women who were illiterate were more likely to be users of long term temporary methods compared to primary (17% less) and secondary educated women (28% less). Uneducated women were more likely to be users of permanent method of contraception, as-well, compared to primary and secondary educated women. Table-2: Multinomial logistic regression of modern contraceptive methods used by females on selected variables, Bangladesh DHS 2004   Odds of taking pill was found to be almost two and a half times higher in women having one living son compared to those having no living son. Couples with one or two sons preferred condom twice (1.8 and 2.02) more than those having no son. Having at least one son increased the odds of using long term and permanent methods by more than 2.5 and 3.5 times, respectively compared to women having no living son. From the table it was observed that Muslim women were significantly lower users of pill and had less chance of being a permanent method acceptor compared to non-Muslim women. Religion turned out to be an insignificant predictor for condom use. Contrary to expectation, the study finding showed that Muslim women had 1.56 times more probability of being acceptors of long term temporary methods than non-Muslim women. The model showed that women living in urban areas had higher odds of being users of modern contraceptive methods than women living in rural areas. Division also mattered in the pattern of contraceptive use. Using Sylhet as the reference category, it was found that the women, who were from Rajshahi division, showed highest odds of using all types of modern contraceptive methods; use of pill was 5 times higher in women from Rajshahi compared to women from Sylhet. Compared to women who lived in Dhaka division, condom use were significantly less among women of Barisal and Sylhet divisions. Data of Rajshahi, Khulna and Barisal division showed higher use of long term methods of contraception by the women in these divisions compared to those in Dhaka, whereas women in Sylhet again showed poorer performance. Husbands who had higher education showed 2.4 times more likelihood of being a condom user compared to those who were uneducated. Husband’s level of education was an insignificant predictor of pill use by their wives. Husband with secondary or higher education showed 0.19 and 0.46 times lower odds of their wives using long term temporary methods compared to non-educated husbands, uneducated husbands preferred the permanent method, whereas, probability of using this method decreased by 25% if educational status increased to secondary education. Discussion Among the other factors, the status of women also depend on whether she can move outside of the homestead alone, thus enabling a woman to cross several socio-cultural barriers7. This ‘mobility’ also has influences over her contraceptive behavior. Higher odds in use of all types of modern methods were observed in women having higher mobility score. To achieve higher rates of contraceptive prevalence, there is a need for widespread measures that will enhance the mobility of the women. Kamal and Mohsena(2011) made recommendations for extending projects like Grameen Bank and Bangladesh Rural Advancement Committee (BRAC) for achieving further autonomy of women6. Interestingly, finding of this study suggests that woman’s membership with an NGO increased her probability of using the pill, sterilization and long-term methods, but condom use was almost the same between women involved or not involved with NGOs. This may be due to the reason that NGOs are now providing family planning services along with their credit programs10; but their service effort probably is targeted to overall contraceptive prevalence rate (CPR). In these days of impending epidemic of AIDS and higher prevalence of sexually transmitted diseases (STDs) use of condom can serve as double protection, both against unwanted fertility and STDs/ HIV. During group-participation of women in NGOs promotion of condom use could be successful. One advantage to be noted here is that influence of religious beliefs in this regard is negligible. Gender discrimination and preferences for sons are key demographic features in South Asia12; Bangladesh being no exception. After the birth of oneson, the odds of using all types of contraceptives increase, ranging from 1.8 to 3.7. This existence of son preference in a region, where the official target is to decline fertility, has implications for future population policy. This sex preference is likely to correlate with women’s autonomy. Girls are not encouraged to engage in any economic activities outside their homes and an associated custom is the practice of dowry payments. These norms always impoverish the parents of girls and enrich the parents of boys. The improvement of women’s status, their education levels, their employment and the value of girls in the society should therefore be future policy measures. The study findings of this study have a number of policy implications for Bangladesh. The measures that are expected to be useful in devising ways to increase the Contraceptive Prevalence Rate and thus bring about a further reduction in fertility in Bangladesh are multidimensional. Provision of education and employment to women, as well as their male counterpart proved to be the key policy. Policy should be targeted to prevent high dropout rates from secondary schools, which in turn will enable them to get greater degree of autonomy. Kamal and Haider (2006)15 also recommended that providing free female education alone cannot let the chair stand, it comprises of only one leg, the other legs need to be in place as well. Campaigns should be done to raise the value of girl child in the society and reduce son preference. Demographers have associated ‘Dowry’ as a major cause of son preference. Motivational campaigns and application of legislation strictly may turn out to be the solution. Besides, improving the employment situation of women will also enable them in obtaining some family power to make family planning decision. Improving the home visit of the family planning workers should be highlighted in policy, as this visit still comes out as a strong predictor of contraceptive use.Various researches showed that role of NGOs in women empowerment are encouraging; where women empowerment is defined as a function of her relative physical mobility and economic security. Contraceptive awareness may be targeted to the credit-receiving clients; involvement of the NGOs in advocating contraceptive use, especially in promoting condom may give better result. Reference 2.    Menken J and Rahman MO. Reproductive Health. In: H MM, E BR, J MA, editors. International Public Health Diseases, Programs, Systems and Policies Gaythersburg, Maryland: Aspen Publishers 2001. 4.    Islam MM, Islam MA and Chakroborty N. Fertility Transition in Bangladesh: Understanding the Role of the Proximate Determinants. Journal of Biosocial Science 2004; 36(3): 351-69. 6.    Kamal N and Mohsena M. Twenty Years of Field Visits by Family Planning Workers in Bangladesh: Are They Still Needed? The Indian Journal of Family Welfare 2011; 57(1): 10-21. 9.    Amin S, Selim N and Kamal N. Causes and Consequences of Early Marriage in Bangladesh. Background Report for Workshop on Programs and Policies to Prevent Early Marriage. Dhaka, Bangladesh: Population Council 2006. 11.  Kamal N. Role of Government Family Planning Workers and Health Centres as Determinants of Contraceptive Use in Bangladesh. Asia-Pacific population Journal/United Nations 1994; 9(3): 59-65. 13.  Ullah MS and Chakraborty N. The Use of Modern and Traditional Methods of Fertility Control in Bangladesh: A Multivariate Analysis. Contraception 1994; 50(4): 363-72. 15.Kamal N and Haider S. Role of Education in Enabling Empowerment of Women in Bangladesh.CHPD Seminar Series; 15 March; IUB, Bangladesh 2006. 2026 Ibrahim Medical College. All rights reserved.